Provider Demographics
NPI:1356708234
Name:FICKLE, STEPHANIE (MA, LAPC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:FICKLE
Suffix:
Gender:F
Credentials:MA, LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 WOODVIEW LN
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6074
Mailing Address - Country:US
Mailing Address - Phone:404-455-0185
Mailing Address - Fax:
Practice Address - Street 1:2450 ATLANTA HWY
Practice Address - Street 2:SUITE 1901
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-8099
Practice Address - Country:US
Practice Address - Phone:770-744-1324
Practice Address - Fax:678-456-8573
Is Sole Proprietor?:No
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC005075101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional